Art of diagnosis: Paintings sharpen med students' skills

For first-year students at Yale Medical School, training includes a visit to the Yale Center for British Art, where these future doctors hone their observational skills by examining centuries-old paintings in thick, gold frames.

"We try to treat the painting as you would a patient, an unknown patient," Kalman Watsky, a clinical professor of dermatology at the Yale School of Medicine, who conducts these observational training sessions, told a group of visiting science writers. “The goal is to observe closely what you see without making a judgment.”

Like patients suffering from symptoms with an unknown cause, the paintings offer mysteries waiting to be deciphered. Those used in the observational training tell a story, but it is often ambiguous, and cues meant for viewers centuries ago are often lost on a modern audience.

Examining a painting

At the demonstration last Sunday, the group stopped in front of what appeared to be a somber portrait of a family. The foreground of the 17th-century painting contained three children, with a mother and father behind them. Watsky gave the visitors a few moments to study it before giving descriptions vivid enough to create a mental image for someone who couldn't see the painting.

Early on, the visitors' attention gravitated to the portrait's backdrop. To the left, behind the father, a drapery was pulled back, as if to open a passageway. On the right, behind the mother, human skulls sat atop a pedestal.

The visitors continued making observations, and Watsky directed them toward significant details and pushed them for more specifics. But the endeavor was briefly sidetracked with a discussion of whether the mother at one point had six fingers, as hinted by an odd gap between her fore and middle fingers on the hand gripping the shoulder of a pale child in front of her. Then Watsky redirected the observers' attention to other, more fruitful, details.

“Where are their eyes facing?” he asked. And later, he focused on the father’s expression, and then the mother’s. “What do you make of her lips?”

They seemed tight or pursed. Her eyes confronted the viewer, while the father looked off to the side, perhaps in the direction of the skulls.

Then it was time to find out the truth.

“Everything in this painting was put there for a definite purpose,” he said.

In fact, this was indeed a family portrait, but one painted after the pale child the mother clutched had died, and was intended to commemorate the child.

“What did the child die of?” someone asked.

“We have no idea, this is not a medical diagnosis,” Watsky said.

Returning to old skills

This technique was developed more than a decade ago at the medical school to help students become more skillful at diagnosing patients once they became doctors, according to Irwin Braverman, professor emeritus and senior research scientist in dermatology. About 16 other medical schools either are or have employed a similar form of observation training, and it is being developed at others, according to Braverman.

Medical schools teach future doctors to memorize patterns in order to recognize syndromes, which are collections of different signs and symptoms, Braverman said. With a rash, for example, students learn to look for two components: first, the distribution of the rash, and second, the morphology of the individual lesions in the rash. Those two characteristics together allow a doctor to make a diagnosis. However, visual analysis, like that honed by describing the paintings, becomes important when a rash doesn't fit a pattern the doctor recognizes, he told LiveScience in an e-mail.

What's more, since imaging technologies — including magnetic resonance imaging (MRI), computed tomography (CAT) scans — revolutionized medicine in the 1970s, doctors have come to rely on them and become less and less observant, he said.

In 1998, Braverman and others began a two-year study to test whether observational training like this would raise students' scores if after receiving it, their observational skills were tested on photographs of patients with medical disorders. (The students did not have to make a diagnosis based on the photo.) For both years, the students who attended the sessions at the Yale Center for British Art saw their scores increase significantly, according to the results published in the Journal of the American Medical Association in 2001.

By training future doctors to spend extra time observing and listening to their patients, this program counters the trend toward brief interactions with patients, he said. Better observation by doctors also reduces the reliance on imaging technology and expensive tests.